[A couple of weeks ago, graduate students in public health from five states gathered in Boston for a "summit" on the future of public health. Here are some notes I prepared for the occasion. --Peter Montague]

I. "We can do this work but we can't talk about it."

The anecdote of the public health specialist in toxic lead.

This is a true story. An employee of a city health department -- let's call him Albert -- is assigned to reduce lead exposures in children younger than 6. He works in a city dominated by political moderates, with housing built mostly in the 1940s or earlier. The city has substantial black and latino populations, who tend to occupy the oldest housing. As children are tested for toxic lead in their blood, as required by federal law, it is Albert's job to visit families whose children have 20 or more micrograms of lead per tenth of a liter of blood (ug/dL), to look for sources of lead exposure in the home and to inform the parents about ways to reduce exposure. It's slow work, one-on-one, with no end in sight or even imaginable, really.

As part of his job, Albert gives his data to a colleague who makes a computer map (GIS) of the city, displaying each known lead case as a small dot of light against a dark street map.

When the GIS map is displayed showing known cases with 10 ug/dL or higher, there are about a few dozen blocks in the city that light up almost solidly, with other clusters of dots scattered randomly throughout the city.

However, when the data is displayed with known cases of 5 ug/dL or higher, every street in the city lights up like a Christmas tree. Essentially, all the children in the city have been poisoned to some extent by toxic lead. The soils in the city are contaminated from years of lead paint flaking off buildings. Wind blows lead into the air, then into the children. When knowledgeable people first see this Christmas tree map of toxic lead in the city's children, they gasp.

Joe knows that current medical information indicates than even 1 to 2 ug/dL of lead in blood lowers IQ, diminishes attention span, and reduces a person's capacity to cope well with stress and frustration, thus contributing to aggressive and in some cases violent behavior.[1] So he knows that the presence of at least 5 ug/dL in the blood of most of the children in the city is a serious public health problem... a disaster, really.

Joe and I and a dozen other concerned citizens and public health specialists are talking about this problem among ourselves. We decide we need to bring this problem to the attention of the city fathers and mothers -- the "powers that be." However, when someone suggests the obvious way to do this -- to call up a savvy newspaper reporter and show her the health department's map and explain what it means, Albert blanches. "If you do that, I'll be fired for sure," he says, "and the health department's budget for lead work will be cut -- if not this year, then next year. We can do this work, but we can't talk about it," he says. There are murmurs of assent from his colleagues around the table. He adds, "I can't afford to get fired. I've got a kid to support."

The anecdote of the ATSDR professional.

Here is another true story. Recently I met a public health specialist employed by the ATSDR [Agency for Toxic Substances and Disease Registry], a small federal agency employing about 400 public-health specialists, with headquarters in Atlanta. We got to talking about the subject of "fear at work" and she told me that a couple of years ago one of her colleagues, as part of a study he was thinking of doing, sent out an Email to everyone in ATSDR asking them if they ever felt afraid to speak openly about their work. She told me he was "astonished" to receive more than 100 emails in response from professionals who said they felt afraid to speak openly within the agency. Furthermore, there were many other people who were so afraid that they would not respond by Email but would only respond one-on-one in the hallways.

"My colleague was flabbergasted by these expressions of fear throughout the agency," she told me, "because we are all protected here at ATSDR. We can't be fired arbitrarily, only for cause." She stopped. After a few seconds, she added, "I suppose they could make our lives miserable..." and her voice trailed off.

She also told me that shortly after this informal survey was conducted via Email, ATSDR management changed the Email system to make it impossible for anyone except top management to send an Email to everyone in the agency.

II. The source of fear is unchecked power, or the perception of unchecked power.

Who holds power in the U.S.?

To begin, let's talk about how the U.S. is governed. A few years ago, Lewis Lapham, the editor of Harper's magazine, described two governments: the permanent government, which actually governs, and the provisional government which oversees the production of pageants.

"The permanent government, a secular oligarchy... comprises the Fortune 500 companies and their attendant lobbyists, the big media and entertainment syndicates, the civil and military services, the larger research universities and law firms. It is this government that hires the country's politicians and sets the terms and conditions under which the country's citizens can exercise their right -- God-given but increasingly expensive --to life, liberty, and the pursuit of happiness. Obedient to the rule of men, not laws, the permanent government oversees the production of wealth, builds cities, manufactures goods, raises capital, fixes prices, shapes the landscape, and reserves the right to assume debt, poison rivers, cheat the customers, receive the gifts of federal subsidy, and speak to the American people in the language of low motive and base emotion."

Lapham's description of the U.S. is humorous, but also pretty close to the truth.

Lapham distinguishes the "permanent government," which is not elected, from the "provisional government," which is:

"The provisional government is the spiritual democracy that comes and goes on the trend of a political season and oversees the production of pageants.... Positing a rule of laws instead of men, the provisional government must live within the cage of high-minded principle, addressing its remarks to the imaginary figure known as the informed citizen or the thinking man, a superior being who detests superficial reasoning and quack remedies, never looks at Playboy, remembers the lessons of history, trusts Bill Moyers, worries about political repression in Liberia, reads (and knows himself improved by) the op-ed page of the Wall Street Journal," Lapham writes. [2]

Now let's get specific about who rules America. Today 1% of the American people own 50% of all private wealth, and 5% of the American people own 2/3rd of all private wealth.[3]

Think about that: 1% of the people own half of all private wealth in the U.S. That's about 3 million people who have managed to scoop up half the wealth generated by a cooperative effort of 300 million people.

But real decision-making power rests in the hands of even fewer people than that. The truly powerful are the few who sit on multiple boards of transnational corporations. They number roughly 50,000.[4] These are people who can make things happen. It is they who have the power to decide whether the U.S. will go to war. They can decide whether we will have a good system of public schools, or the kind we've got. It is they who can decide whether the corporate globalization project will trump environmental protection and worker rights, or not. It is they who can decide whether the U.S. will have an adequate public health system, or the kind we've got.[5]

This relatively small number of truly wealthy people (whether counted as 50,000 or 3 million) doesn't conspire -- it doesn't need to. Its members all pretty much read the same half-dozen or so newspapers and they all belong to the same kinds of clubs. Their conversations share common assumptions and follow a predictable logic. They all do know which side their bread is buttered on. They aren't fools, after all.

If the truly wealthy decided that the nation's toxic lead problem needed to be fixed, the problem could be cleaned up in fairly short order -- and the country would save bundles of money by cleaning up lead.

That's right: cleaning up lead would pay for itself in increased productivity and earning power of the children not poisoned. More than one study has shown that the U.S. economy would benefit substantially in monetary terms from cleaning up toxic lead [see http://www.rachel.org/library/getfile.cfm?ID=444 and http://www.rachel.org/library/getfile.cfm?ID=468 for example] -- not to mention the heartbreak, the pain, and the terrible sense of waste and loss that could be avoided if we stopped poisoning our children and diminishing so many of their possibilities.

But evidently the permanent government does not want to end lead poisoning. And they want public health specialists to feel intimidated for even thinking about speaking out about public health problems. If the truly wealthy didn't want it this way, it wouldn't be this way for long.

(It would be interesting to brainstorm among ourselves, asking why the permanent government might not want the problem of toxic lead in children to be solved.)

III. Inequality as a Major Public Health Problem

I don't know why the permanent government doesn't want public health professionals speaking out about public health issues. (It would be interesting to brainstorm among ourselves about this question.) But I do have a hypothesis:

If public health advocates were free to speak out about public health, many of them would feel compelled to speak out about economic inequality.

It is a fact that there is a large body of scientific and medical literature indicating that inequalities are bad for public health. By "inequalities" I mean inequalities of wealth, income, status, and social standing, which all give rise to inequalities of power (power to control and to decide).[6]

As the New York Times reported June 1, 1999[7] --

"Scientists have known for decades that poverty translates into higher rates of illness and mortality. But an explosion of research is demonstrating that social class -- as measured not just by income but also by education and other markers of relative status -- is one of the most powerful predictors of health, more powerful than genetics, exposure to carcinogens, even smoking.

"What matters is not simply whether a person is rich or poor, college educated or not. Rather, risk for a wide variety of illnesses, including cardiovascular disease, diabetes, arthritis, infant mortality, many infectious diseases and some types of cancer, varies with RELATIVE wealth or poverty: the higher the rung on the socioeconomic ladder, the lower the risk. [Emphasis in the original.]"[7]

It isn't the absolute level of well-being that matters so much as the relative level. Even among the well-to-do, those higher on the social scale are healthier. As the NEW YORK TIMES put it, current research is showing that a mid-level executive in a three-bedroom home in Scarsdale, N.Y. is more vulnerable to illness than his boss who lives in a 5-bedroom home a few blocks away.

BMJ, the British Medical Journal, had announced the importance of inequality to health in an editorial titled, "The Big Idea" in 1996:[8]

"... Big ideas don't often arise, but the BMJ has been associated with several -- and one of them is explored further this week. The big idea is that what matters in determining mortality and health in a society is less the overall wealth of that society and more how evenly wealth is distributed. The more equally wealth is distributed the better the health of that society. One political implication, appealing to those on the left, is that the best way to improve health in a society might be to take measures to distribute wealth as equally as possible." [8]

If economic inequalities are a major source of public health problems, then public health specialists have a professional obligation to work to reduce inequalities, and to speak openly about the problem.

Arguably, inequalities are the largest and most pervasive public health problem, because inequalities contribute to so many specific diseases.

From the viewpoint of the permanent government perhaps it is important to keep public health professionals fearful about speaking out about ANY public health problem because public health professionals are the ONLY group of people in the U.S. who have a professional obligation to advocate for a reduction in inequalities.

If public health professionals got into the habit of speaking out, many of them would soon be speaking out about the public health consequences of gross inequalities, and many would be advocating for policies to reduce inequalities. Where would it end?

IV. What's a student of public health to do?

Here are some suggestions for you to consider:

1) Inform yourselves about the role of inequalities in public health.[6]

2) Inform yourselves about the official positions that public health professional associations have taken. To see relevant position statements by NACCHO, the National Association of County and City Health Officials, go to http://www.rachel.org/library/index.cfm?St=1 and search on NACCHO.

3) Develop a strategy for being effective, consistent with your professional goals, your personality, your ethical beliefs, and so on:

a) You might choose to remain a maverick working on the periphery of public health, but focusing on public health goals.

b) Or you could become a public health insider but build a constituency of people who values your work and would come you your aid in time of need;

c) Join, support, and protect your union AND the right of EVERYONE to form and join a union, to bargain collectively and, if all else fails, to strike. Labor unions -- for all their faults -- are the single most powerful force holding inequalities in check. In this way, unions are an essential and critical component of any successful public health program.

d) Join, work within, and support your professional associations, NACCHO, APHA [American Public Health Association] -- and similar associations at the state level.

e) Learn about whistle blowers and their survival strategies.

f) Work to change the culture of public health so that a public health worker who had important information but who did NOT speak out would feel ashamed and might even feel reproach from colleagues.

How could we change the culture of public health to make the default assumption not silence but an obligation to speak out and to advocate for what we know is right for public health?

Now let's brainstorm about that...

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Notes and references

[1] http://www.rachel.org/bulletin/index.cfm?issue_ID=2466

[2] http://www.rachel.org/library/getfile.cfm?ID=524

[3] Data on our growing inequalities of wealth are available from several sources, but my current favorite is Gar Alperovitz, America Beyond Capitalism; Reclaiming Our wealth, Our Liberty and Our Democracy (Hoboken, N.J.: John Wiley & Sons, Inc., 2005); see pg. 206. See also, for example, Edward N. Wolff, Top Heavy; the Increasing Inequality of Wealth in American and What Can Be Done About It (New York: The New Press, 2002). Another really good book is Michael Zweig's, The Working Class Majority; America's Best Kept Secret (Ithaca, N.Y.: Cornell University Press, 2000); ISBN 0-8014-3637-0.

[5] See, for example, these two statements from NACCHO, the National Association of County and City Health Offcials: http://www.rachel.org/library/getfile.cfm?ID=334 and http://www.rachel.org/library/getfile.cfm?ID=335.

[6] See Rachel's #497 at http://www.rachel.org/bulletin/index.cfm?issue_ID=626 and Rachel's #584 at http://www.rachel.org/bulletin/index.cfm?issue_ID=538

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